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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412525
Report Date: 01/31/2020
Date Signed: 01/31/2020 01:57:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MADRIGAL, EVELIAFACILITY NUMBER:
434412525
ADMINISTRATOR:MADRIGAL, EVELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 310-0298
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 10DATE:
01/31/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Evelia MadrigalTIME COMPLETED:
02:10 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee Evelia Madrigal for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Present were licensee and licensee's assistant and 10 daycare children including. Days and hours of operation are Monday to Saturday, 5:00am to 6:30pm. The adults that reside in the home are licensee and her three roommates.

A review of staff records on 01/21/2020 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed barricaded stairs in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: four upstairs bedrooms, two bathrooms and downstairs laundry room and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: right side of home that is fenced off to children and locked storage. Licensee states there is one dog and it stays in the fenced off area.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MADRIGAL, EVELIA
FACILITY NUMBER: 434412525
VISIT DATE: 01/31/2020
NARRATIVE
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LPA observed licensee has a current CPR and First Aid certification expiring 09/14/2020 and has Mandated Reporter training on 10/15/2018. LPA did not observe a current roster of the children. LPA observed a fire and disaster drill log which was last completed on 08/13/2019. LPA reviewed nine children's files. Child 5, 6, 9 and 10 are missing immunization records or need to be updated. Child 3 and 10 are missing LIC995. Child 10 is missing entire file. LPa observed day care is insured with Western World. LPA discussed SB792 Immunization Requirements and observed assistant does not have record of immunization against pertussis, measles and influenza. LPA did not observe a file for assistant Maria Palomares.


Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and licensee understands the requirements. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA reminded the Licensee that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensee. Safe sleep information & handout was also discussed with the Licensee.


The following type B deficiencies were cited. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MADRIGAL, EVELIA
FACILITY NUMBER: 434412525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2020
Section Cited

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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement was not met as evidenced by LPA did not observe a current roster of the children.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/14/2020
Section Cited

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102416.1(a) Personnel Records. Personnel records shall be maintained on each employee and shall contain specified information. This requirement was not met as evidenced by LPA did not observe a file for assistant Maria Palomares.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MADRIGAL, EVELIA
FACILITY NUMBER: 434412525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2020
Section Cited

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102416.1(a)(10) Personnel Records. Personnel records shall contain a signed and dated copy of the Notice of Employee Rights (LIC 9052).
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This requirement was not met as evidenced by LPA did not observe a file for assistant Maria Palomares. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/14/2020
Section Cited

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102416.1(a)(11) Personnel Records. Personnel records shall contain a signed statement regarding their criminal record history, and shall contain specified information.
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This requirement was not met as evidenced by LPA did not observe a file for assistant Maria Palomares. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MADRIGAL, EVELIA
FACILITY NUMBER: 434412525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2020
Section Cited

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102369(b)(9) Application for License. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment.
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This requirement was not met as evidenced by LPA did not observe a file for assistant Maria Palomares. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/14/2020
Section Cited

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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by Child 5, 6, 9 and 10 are missing immunization records or need to be updated.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MADRIGAL, EVELIA
FACILITY NUMBER: 434412525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2020
Section Cited

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102421(a) Childs Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice.
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This requirement was not met as evidenced by Child 3 and 10 are missing LIC995.This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/14/2020
Section Cited

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102421(b) Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7).
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This requirement was not met as evidenced by Child 10 is missing entire file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MADRIGAL, EVELIA
FACILITY NUMBER: 434412525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2020
Section Cited

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1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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This requirement was not met as evidenced by assistant does not have record of immunization against pertussis, measles and influenza. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 7 of 7